160 A CLOSED-LOOP AUDIT EXAMINING THE USE OF PROPHYLACTIC ANTI-COAGULATION IN OLDER ADULTS ADMITTED TO A SPECIALIST GERIATRIC SERVICE

Background

Guidelines recommend prescription of Prophylactic Anticoagulation (PA) to all hospitalized older adults unless a contraindication exits. In many cases this does not happen at the time of admission increasing the risk of thromboembolic events. We aimed to assess the use of PA across the medicine for the geriatric service of a level 3 hospital (average daily census of service 120) then use quality improvement to achieve our goal of 95% prescription of prophylactic anticoagulation when appropriate.

Methods

Medication kardexes and clinical notes were reviewed to collect variables including age, length of stay, creatinine clearance, weight, mobility status, use and dose of antithrombotic medications and documentation of reason if not prescribed. Following initial data collection, cause and effect analysis was performed to identify reasons for under-prescription and small tests of change were conducted across 4 PDSA cycles before data collection was repeated.

Results

Initial data collection revealed that only 80% of older adults admitted to the service were receiving prophylactic anticoagulation. Cause and effect analysis identified many reasons for failure to prescribe PA including inadequate history taking, lack of clinician education and training, poor documentation, lack of handover between clinicians, failure to complete medication reconciliation on admission and lack of pharmacy support on some wards. Each of these contributory factors were addressed in turn. After a month of QI activities prescription of PA improved to 83% and by 3 months 98.1% (104/106) of patients were receiving PA with only 2 patients for whom PA was not prescribed without clear documentation of the reason.

Conclusion

Sustained quality improvement resulted in a culture change across our service improving rates of appropriate prescription of PA and raising the quality of care delivered to older adults. This model of quality improvement is now being replicated across our department to address other gaps in service delivery.

Comparative efficacy of Ovaprim and hMG (menotropin) to induce breeding in African catfish (Clarias gariepinus)

The applications of exogenous hormones in different species for the induction of oocyte production, final oocyte maturation (FOM), and spawning for their reproduction is getting more attention day by day. The current preliminary research work was carried out to induce breeding in Clarias gariepinus, commonly known as African catfish, imported from Thailand. Single doses of two hormones as Ovaprim and human menopausal gonadotropin (hMG) were used and the research work was carried out at Muzaffargarh Fish Hatchery Punjab, Pakistan. A total of twenty-four (n = 24) C. gariepinus were selected having body weight approximately 2 kg and divided into two main groups based on gender as male (n = 12) and female (n = 12). For milt collection, all males were treated with Ovaprim 0.5 mg/kg body weight (b.w.) and female fish were divided into three groups as A, B, and C with four (n = 4) fish in each group. Group A was injected with only normal saline (control group) while fish in group B and group C were treated with hMG at 0.5 mg/kg b.w. and Ovaprim 0.5 mg/kg b.w., respectively. Then, after 6 h of hormone injections until 48 h, spawned eggs, eggs' weight, fertilization rate, hatching rate, survival rate, fecundity, and deformed larvae were investigated. The results revealed that Ovaprim injection significantly (p < 0.05) modulate the reproductive parameters in group C while no breeding was induced in both control and hMG-treated groups. Hence, it could be concluded that Ovaprim has the potential to induce breeding in African catfish, while in the current study, hMG failed to induce breeding. However, trials at large scales are required to further explore the effect of different doses of both tested hormones by increasing the treated subjects particularly in Pakistani fish farms.

Reclassification of aortic stenosis by fusion of echocardiography and computed tomography in low-gradient aortic stenosis

Background

The integration of computed tomography (CT)-derived left ventricular outflow tract area into the echocardiography-derived continuity equation results in the reclassification of a significant proportion of patients with severe aortic stenosis (AS) into moderate AS based on aortic valve area indexed to body surface area determined by fusion imaging (fusion AVA_i). The aim of this study was to evaluate AS severity by a fusion imaging technique in patients with low-gradient AS and to compare the clinical impact of reclassified moderate AS versus severe AS.

Methods

We included 359 consecutive patients who underwent transcatheter aortic valve implantation for low-gradient, severe AS at two academic institutions and created a joint database. The primary endpoint was a composite of all-cause mortality and rehospitalisations for heart failure at 1 year.

Results

Overall, 35% of the population (n = 126) were reclassified to moderate AS [median fusion AVAi 0.70 (interquartile range, IQR 0.65–0.80) cm²/m²] and severe AS was retained as the classification in 65% [median fusion AVAi 0.49 (IQR 0.43–0.54) cm²/m²]. Lower body mass index, higher logistic EuroSCORE and larger aortic dimensions characterised patients reclassified to moderate AS. Overall, 57% of patients had a left ventricular ejection fraction (LVEF) <50%. Clinical outcome was similar in patients with reclassified moderate or severe AS. Among patients reclassified to moderate AS, non-cardiac mortality was higher in those with LVEF <50% than in those with LVEF ≥50% (log-rank p = 0.029).

Conclusions

The integration of CT and transthoracic echocardiography to obtain fusion AVAi led to the reclassification of one third of patients with low-gradient AS to moderate AS. Reclassification did not affect clinical outcome, although patients reclassified to moderate AS with a LVEF <50% had worse outcomes owing to excess non-cardiac mortality.

0008 SUVN-G3031, A Histamine H3 Receptor Inverse Agonist Produces Robust Wake Promoting and Anticataplectic Activity in Orexin Knockout Mice

Introduction

Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness, sleep paralysis, hallucinations, and in some cases episodes of cataplexy. Results from animal studies indicate the involvement of deficient orexin transmission in narcolepsy which can be circumvented by the activation of histaminergic neurons. SUVN-G3031 is a potent and selective histamine H3 receptor inverse agonist with hKi of 8.7 nM and shows less than 50% inhibition at 1 µM against 70 other targets. SUVN-G3031 exhibited excellent pharmacokinetic properties and brain penetration in preclinical species. Oral administration of SUVN-G3031 produces significant increase in histamine, dopamine and norepinephrine levels in the rat cortex. Long-term safety studies in animals have been successfully completed without any concern for further development of SUVN-G3031. In the present study, the effects of SUVN-G3031 were evaluated in orexin knockout mice, a reliable animal model of narcolepsy as a proof-of-concept study for the treatment of narcolepsy with and without cataplexy.

Methods

Male orexin knockout mice (10 - 15 weeks old, 25 - 35 g at the time of surgery) were implanted with telemetric device for simultaneous monitoring of electroencephalography (EEG) and electromyography. Animals were allowed surgical recovery of 3 weeks prior to EEG recording. Effects of SUVN-G3031 (3 and 10 mg/kg, p.o.) were evaluated during active period of animals.

Results

SUVN-G3031 produced significant increase in wakefulness with concomitant decrease in non-rapid eye movement sleep in orexin knockout mice. SUVN-G3031 also significantly decreased the number of cataplectic episodes in orexin knockout mice.

Conclusion

Results from the current preclinical study provide a strong basis for the utility of SUVN-G3031 for the treatment of narcolepsy with and without cataplexy. SUVN-G3031 is currently being evaluated in a Phase 2 study as monotherapy for the treatment of narcolepsy with and without cataplexy (ClinicalTrials.gov Identifier: NCT04072380).

Support

None

Characterizations and morphology of sodium tungstate particles

A solid-state reaction technique was used to synthesize polycrystalline Na₂WO₄. Preliminary X-ray studies revealed that the compound has a cubic structure at room temperature. The formation of the compound has been confirmed by X-ray powder diffraction studies and Raman spectroscopy. Electrical and dielectric properties of the compound have been studied using complex impedance spectroscopy in the frequency range 209 Hz-1 MHz and temperature range 586-679 K. The impedance data were modellized by an equivalent circuit consisting of series of a combination of grains and grains boundary. We use complex electrical modulus M* at various temperatures to analyse dielectric data. The modulus plots are characterized by the presence of two relaxation peaks thermally activated. The morphologies and the average particle size of the resultant sodium tungstate sample were demonstrated by atomic force microscopy, scanning electron microscopy and transmission electron microscopy. The thicknesses and optical constants of the sample have been calculated using ellipsometric measurements in the range of 200-22 000 nm by means of new amorphous dispersion formula which is the objective of the present work. The results were obtained for Na₂WO₄ particles from experimental (EXP) and measured (FIT) data showed an excellent agreement. In addition, the energy gap of the Na₂WO₄ sample has been determined using ellipsometry and confirmed by spectrophotometry measurements.

Uncertainty Quantified Computational Analysis of the Energetics of Virus Capsid Assembly

Most of the existing research in assembly pathway prediction/analysis of viral capsids makes the simplifying assumption that the configuration of the intermediate states can be extracted directly from the final configuration of the entire capsid. This assumption does not take into account the conformational changes of the constituent proteins as well as minor changes to the binding interfaces that continue throughout the assembly process until stabilization. This paper presents a statistical-ensemble based approach which samples the configurational space for each monomer with the relative local orientation between monomers, to capture the uncertainties in binding and conformations. Furthermore, instead of using larger capsomers (trimers, pentamers) as building blocks, we allow all possible subassemblies to bind in all possible combinations. We represent the resulting assembly graph in two different ways: First, we use the Wilcoxon signed rank measure to compare the distributions of binding free energy computed on the sampled conformations to predict likely pathways. Second, we represent chemical equilibrium aspects of the transitions as a Bayesian Factor graph where both associations and dissociations are modeled based on concentrations and the binding free energies. We applied these protocols on the feline panleukopenia virus and the Nudaurelia capensis virus. Results from these experiments showed significant departure from those one would obtain if only the static configurations of the proteins were considered. Hence, we establish the importance of an uncertainty-aware protocol for pathway analysis, and provide a statistical framework as an important first step towards assembly pathway prediction with high statistical confidence.

Drinking water: a major source of lead exposure in Karachi, Pakistan

Excess lead in drinking water is a neglected source of lead toxicity in Pakistan. A cross-sectional survey in 2007/08 was made of water samples from drinking water sources in Karachi, a large industrial city. This study aimed to compare lead levels between untreated ground water and treated surface (tap) water in 18 different districts. Of 216 ground and surface water samples collected, 86% had lead levels higher than the World Health Organization maximum acceptable concentration of l0 ppb. Mean lead concentration in ground water [146 (SD 119) ppb] was significantly higher than in surface water [77.1 (SD 54) ppb]. None of the 18 districts had a mean lead level of ground or surface water below the WHO cut-off and ground water sources in 9 districts had a severe level of contamination (>150 ppb). Urgent action is needed to eliminate sources of contamination.

The computed tomography diagnosis of paracecal hernia

Paracecal or pericecal hernia is a rare type of internal hernia that causes intestinal obstruction, and its correct preoperative diagnosis is rarely made. Its computed tomography (CT) features are sufficiently characteristic to permit an accurate diagnosis. We present the CT features of a case of paracecal hernia complicated by strangulation to facilitate its early recognition by radiologists and surgeons.

Influence of prior pregnancies on disease course and cause of death in systemic sclerosis

BACKGROUND

Microchimerism from fetal or maternal cells transferred during pregnancy has been implicated in the pathogenesis of systemic sclerosis (SSc).

OBJECTIVE

To determine whether a prior pregnancy influenced disease progression and cause of death in patients with SSc.

PATIENTS AND METHODS

The patients comprised a retrospective study cohort of 111 women with SSc: 78 patients with prior pregnancies (PP) and 33 who were never pregnant (NP), followed up at Thomas Jefferson University. Differences in age at onset, disease subset, organ involvement, cause of death, and type of antinuclear autoantibodies were evaluated statistically, including regression analysis.

RESULTS

The age at onset of SSc in NP patients was 32.0 years compared with 45.7 years in patients with one or two prior pregnancies (p<0.0001), 46.6 years in patients with three or four pregnancies (p<0.0001), and 51.3 years in patients with five to seven pregnancies (p<0.0005). In the 16 patients who had an elective pregnancy termination, 14/16 (87.5%) had diffuse SSc v 2/16 (12.5%) with limited SSc (p<0.0001; odds ratio (OR)=49.0). Of the NP women, 7/30 (23%) died from SSc related causes v 3/78 (4%) women who had pregnancies (p=0.0058; OR=7.6). A carbon monoxide transfer factor (TLCO) of <60% and disease duration >10 years was found in 10/13 (77%) NP patients v 10/23 (43%) patients who had pregnancies (p=0.05; OR=4.7), and a TLCO <50% and disease duration >10 years was identified in 7/13 (54%) NP patients v 6/23 (26%) of the patients who had pregnancies (p=0.09; OR=3.2).

CONCLUSIONS

There are differences in the age at onset, clinical course, severity of lung involvement, and cause of death in women who develop SSc before pregnancy compared with those who develop it after pregnancies. The NP patients with SSc had onset of disease at an earlier age, more severe lung involvement, and higher rate of death due to SSc.

Endoscopic exploration of Red Sea coral reefs reveals dense populations of cavity-dwelling sponges

Framework cavities are the largest but least explored coral reef habitat. Previous dive studies of caverns, spaces below plate corals, rubble and artificial cavities suggest that cavity-dwelling (coelobite) filter-feeders are important in the trophodynamics of reefs. Quantitative community data are lacking, however, as the bulk of the narrow crevices interlacing the reef framework are inaccessible to conventional analysis methods. Here we have developed endoscopic techniques to explore Red Sea framework crevices up to 4 m into the carbonate rock, revealing a large internal surface (2.5-7.4 m2 per projected m2 reef) dominated by encrusting filter-feeders. Sponges alone provided up to 60% of coelobite cover, outweighing epi-reefal filter-feeder biomass by two orders of magnitude. Coelobite community filtration removed more than 60% of the phytoplankton in the course of its less than 5-minute passage through the crevices, corresponding to an uptake of roughly 0.9 g carbon m-2 d-1. Mineralization of the largely allochthonous organic material is a principal source of nutrients supporting coral and algal growth. The supply of new material by coelobites may provide a key to understanding the 'coral reef paradox'-a rich ecosystem thriving in nutrient-poor water.

Triterpenoids of the fruit coats of azadirachta indica

Three new triterpenoids, azadironolide [24,25,26, 27-tetranorapoeupha-7alpha-acetoxy-23xi-hydroxy-21,23-epoxy-1,14, 20(22)-trien-3,21-dione] (1), isoazadironolide [24,25,26, 27-tetranorapoeupha-7alpha-acetoxy-21xi-hydroxy-21,23-epoxy-1,14, 20(22)-trien-3,23-dione] (2), and azadiradionolide [24,25,26, 27-tetranorapoeupha-7alpha-acetoxy-21,23-epoxy-1,14,20(22)-trien-3, 16,21-trione] (3), were isolated from the fresh fruit coats of Azadirachta indica. Their structures have been elucidated through spectral analysis.

A new technique for treatment of simple post-prostatectomy urinary incontinence: preliminary experience

PURPOSE

Because of the complexity of reconstructive surgical techniques, the high failure rate and cost of the devices used, as well as the associated mechanical malfunctions there is need for an alternative operation to treat post-prostatectomy urinary incontinence. We present a new procedure along with promising results in cases of simple post-prostatectomy incontinence after transurethral resection of the prostate or open prostatectomy.

MATERIALS AND METHODS

The principles of our technique include lysis of the pelvic urethra with preservation of the neurovascular bundle, as well as suspension of the prostatic capsule to the anterior abdominal wall. With this technique we corrected post-prostatectomy sphincteric incompetence in 21 patients. Preoperative evaluation included physical examination, excretory urography, ascending urethrocystography and urethrocystoscopy. Urodynamic investigations included uroflowmetry, cystometrography and urethral pressure profilometry. The patients were reevaluated radiologically and urodynamically 3 months postoperatively. Mean followup was 19 months.

RESULTS

All patients tolerated the procedure well. Few intraoperative and postoperative complications were encountered. The success rate was 81% and these 17 patients became continent day and night.

CONCLUSIONS

Our procedure combines the continence enhancing features of pelvic urethral elongation, urethral suspension, angulation of the prostatomembranous junction and prostatic fixation. The preliminary success rate of this technique is encouraging. However, larger numbers of patients and long-term followup are needed to confirm our findings.

Onchocerciasis in Sudan: the Abu Hamed focus

The current status of onchocerciasis in Abu Hamed, Northern Province, Sudan, was studied. Of 208 persons attending out-patient clinics in villages in this region, 71 were microfilariae-positive on skin snips or had palpable nodules. Microfilariae and worms in nodules were identified as Onchocerca volvulus. No microfilariae were seen in peripheral blood. Most nodules and microfilariae were found in the pelvic region, but the intensity of infection was uniformly low (av. less than 3 mf/mg). Despite this, signs of onchocercal dermatitis were common and severe, especially over the buttocks. Papular eruptions and scarring often appeared to lead to black-grey hyperpigmentation, but no cases were seen of the unilateral, hyper-reactive 'sowda' described in Arabs in Yemen. No microfilariae were detected in the eyes of any of the patients who had positive outer canthus snips. Serum retinol concentrations were normal but mildly elevated concentrations of serum IgG, IgM and IgA were detected in many patients. Immunoglobulin E values in a sample of 20 microfilariae-positive patients were markedly higher than normal, with most in the 4,000 to 15,000 U/ml range. Eosinophil levels in differential counts of peripheral blood from the 208 villagers were markedly elevated. In skin snip surveys of over 400 villagers and school pupils, sample prevalence rates of 2 to 17.5% were recorded. Simulium biting was seasonal (November to May) and peaked in March. Over-all, the results indicate that O. volvulus infection persists in the Abu Hamed region as a serious cause of skin disease in the absence of other complicating filariases.